MEDICARE: CROSS CREEK MANOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	UT
2	323P00000X	Psychiatric Residential Treatment Facility	UT
3	3245S0500X	Children's Substance Abuse Rehabilitation Facility	UT

General Provider Information

NPI Number	:	1780900464
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSS CREEK MANOR

Provider Business Mailing Address
First Line	:	50 S STATE ST
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-5443
Country	:	US
Telephone Number	:	435-635-2390
Fax Number	:	435-635-2778

Provider Business Practice Location Address
First Line	:	50 S STATE ST
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-5443
Country	:	US
Telephone Number	:	435-635-2390
Fax Number	:	435-635-2778

Authorized Official
Title or Position	:	CPA
Name	:	DERRICK ESPLIN
Credential	:
Telephone Number	:	435-635-2390

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	04/20/2010

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Directions to “CROSS CREEK MANOR ” Practice Location

Language	Start Address	Practice Location

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